Provider Demographics
NPI:1861611212
Name:MUNSON, JILL SANDRA (LCSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:SANDRA
Last Name:MUNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3777 S WHITNALL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-3931
Mailing Address - Country:US
Mailing Address - Phone:414-769-9428
Mailing Address - Fax:
Practice Address - Street 1:1442 N FARWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2996
Practice Address - Country:US
Practice Address - Phone:414-276-3455
Practice Address - Fax:414-276-3460
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4073-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40932500Medicaid